I. Reassessing Vulnerabilities During a Pandemic
A general problem across all conventional models is their failure to understand that vulnerabilities during a pandemic are created and compounded by socio-economic factors too. Therefore, there is a need to adopt approaches that holistically assess the correlation between socioeconomic factors and vulnerability during a pandemic.[1]
The Syndemics Approach
Under this approach, pandemics are understood as an interaction of that disease with other diseases and the socio-economic and political factors that increase the risk of vulnerability.[2] All these factors synergistically interact to impact the health of individuals and society. Through these risk factors, it identifies the overlapping health and socio-economic problems that increase vulnerability (‘syndemic vulnerabilities’). The socio-economic risk factors are influenced by social determinants of health, i.e., the conditions of housing, food, employment, healthcare, and education.[3] Therefore, the utility of this approach lies in its holistic conception of socio-economic factors that impact the formation, clustering, and progression of diseases.[4] Using this approach, I argue that the COVID-19 pandemic has synergistically interacted and exacerbated the existing diseases and socio-economic conditions of marginalized groups across countries.
Higher Risks of Infection, Transmission, and Mortality: Typically, due to historic discrimination and denial, marginalized communities have a greater number of pre-existing diseases like diabetes and asthma,[5] which in turn elevates their risk of infection and mortality. Moreover, there is unequal access to healthcare among marginalized communities due to the high costs of medical care and the absence of health insurance.[6] Marginalized communities are also disproportionately poor,[7] which affects their ability to mitigate the impact of the pandemic.
Typically, marginalized communities are housed in crowded neighbourhoods with smaller houses that lack outside space.[8] They also have higher population densities, especially in urban areas, and lower access to communal green space.[9]Due to historic discrimination, marginalized communities are over-represented in essential services, including low-wage healthcare sectors and sanitation jobs.[10] This reduces their ability to work from home, and thus increases their risk of infection and transmission. Marginalized communities are more likely to take public transportation,[11] which further increases their risk of infection and transmission.
These syndemic vulnerabilities have increased the risk of mortality among these marginalized communities. For instance, in America, the mortality rate of African-Americans and Indigenous/Latino communities is 3.4 times and 3.3 times higher than a non-Hispanic White person.[12] Evidence from past epidemics/pandemics shows that the rates of infection and mortality are always disproportionately higher among marginalized communities.[13]
Greater Socio-Economic Disruption: Due to a lack of quality education, members of marginalized communities tend to work in lower-wage jobs in the informal sector, which has been worst hit by the pandemic.[14] The percentage fall in employment for marginalized communities has been far greater, indicating that education was a protective factor in the first wave of job losses.[15] Consequently, there has also been greater housing evictions among these communities.[16]The access to quality education for children in marginalized communities has also been severely impacted because they lack access to the internet,[17] affecting their ability to access education. Moreover, low literacy among adults in marginalized communities indicates their inability to assist their children with any form of home learning.[18]
Therefore, the increased syndemic vulnerabilities of marginalized communities and the consequent disproportionate socio-economic disruptions of the pandemic on them necessitate a greater strive for their inclusion in distributing the vaccine. Early access to such vaccines allows these groups the opportunity to proportionately mitigate these vulnerabilities and disruptions.
Intersectionality
Presently, vulnerabilities among individuals are dominantly viewed from a single-axis framework. This ignores the multiple layers and experiences of vulnerability, resulting from an interplay of power structures and different social identities, held by one individual. This ignorance is avoided when using intersectionality, which is an analytical framework that explains how different social, economic, and political identities overlap to create different modes of discrimination and privilege.[19] Thus, it explains how certain individuals in the population are relatively more disadvantaged than others.[20] Intersectionality not only provides a multi-layered understanding of vulnerabilities during a pandemic but also helps prioritize distribution within an identified category, given the scarcity of vaccines.
II. Proposing a Multi-Value Ethical Framework
Given its rational criteria, incorporating utilitarianism’s clinical risk factors is quite valuable. However, as argued, vulnerability during a pandemic is also determined by socioeconomic risk factors. Therefore, there is a need to adopt a multi-value approach that incorporates both clinical and socio-economic risk factors. I propose to do so by simultaneously prioritizing the values of ‘collective wellbeing’ and ‘justice’.
Borrowed from utilitarianism is the value of ‘collective wellbeing’, which aims at maximizing benefits and minimizing harms. Flowing from a syndemic conception of COVID-19 is the value of ‘justice’, which aims at reducing health inequities and treats like people alike. These values are not necessarily always distinct, but their overlap over one parameter indicates a stronger justification. They can be operationalized using an ‘intersectional multi-parameter weighted framework’.
Operationalizing Values
The framework is constructed through three layers: (1) for each risk parameter, there is (2) a value-based justification, along with (3) its extent of weightage. The risk parameters are viewed from an intersectional power axis, with value justifications sourced from clinical and syndemic vulnerabilities. The weightage typically connotes a three-point scale, where 3 indicates the highest priority, and 1 indicates the lowest. The priority order is based on the greatness of one’s total score. The lottery method should only be used as a tie-breaker when the score is the same, and no more doses are presently available.
Age: Older people are at a significantly higher risk of infection and severe morbidity or mortality due to physiological changes associated with ageing. Globally, more than 95% of COVID-19 deaths were among individuals aged 60 and above. Even among older people, more than half of all deaths occurred in people aged 80 and above.[21]
Therefore, in descending order, weightage must be given to individuals above 80 years, individuals between 60-80 years, and individuals between 40-59 years.
Comorbidities: Depending on the country, between 48-75% of COVD-19 deaths are associated with existing comorbidities. Those with comorbidities are also at moderately higher risk of infection.[22]
The prioritization has to be categorized based on the severity of the comorbidity, in contracting the infection and causing death. Therefore, in descending order, higher weightage must be given to severe comorbidities, moderate comorbidities, and mild comorbidities. The severity in infection and mortality is different for countries due to distinct socio-economic realities and evolutionary biology. Therefore, this identification and classification need to be uniquely undertaken. However, as a general rule, it is almost universal for HIV, cancer, and most cardiovascular diseases to be severe comorbidities.[23]
Profession: Prioritizing frontline healthcare, sanitation, and defence workers are justified because they engage in services, whose absence has the greatest negative societal impact- whether on health, safety/security, or economy. They are also in constant contact with areas and people having the greatest risk of infection. Therefore, protecting them has a multiplier effect, in that their ability to remain uninfected protects the health of others and minimizes societal and economic disruption. Since the state obligates these workers to work in risk conditions, while everyone else is working from home, it is further obligated to protect them.
Therefore, in descending order, priority must be given to frontline workers, workers in other essential sectors, and workers in non-essential sectors.
Income: One’s economic status affects their ability to access healthcare, thus results in higher rates of mortality and severe morbidity.[24] The syndemic approach reveals that poverty compounds one’s syndemic vulnerability.
Therefore, in descending order, priority must be given to individuals with low-income, middle-income, and high-income.
Ethnic Identity: The syndemic approach reveals that marginalized communities are at a greater risk of infection, transmission, and mortality. They are also worst affected by the pandemic, which further compounds their vulnerability. Given these vulnerabilities, prioritized vaccine access to marginalized communities also helps reduce all three risks among the general population.
The prioritization criteria would depend on the marginalized communities within a country and the extent of their syndemic vulnerabilities. For instance, in America, the syndemic vulnerabilities are greatest for African-Americans, followed by the Indigenous/Latinos communities, and then Pacific Islanders.
Conclusion
The conventional models of vaccine distribution are unethical towards disadvantaged groups. While neoliberalism completely ignores the distributive function of law, utilitarianism, lottery, and FCFS at least acknowledge this. However, their criterion of distribution ignores socio-economic vulnerabilities. This ignorance can be addressed using a syndemics approach and intersectionality.
The syndemics approach explains the socio-economic risk factors that disproportionately disadvantage marginalized communities, both medically and socio-economically. Intersectionality provides a layered understanding of how vulnerabilities affect people, even those in the same group, differently. Using these approaches, I propose a multi-value ethical framework that balances the pragmatic considerations of medical utilitarianism with greater social inclusion. It operationalizes the values of these ethical systems through the priority order generated under an ‘intersectional multi-parameter weighted framework’.
Notes:
[1] While each country has different marginalized groups, the patterns of vulnerability explored are similar. Thus, marginalized groups have been generally analyzed hereinafter.
[2] Merrill Singer, Nicola Bulled, et al, ‘Syndemics and the biosocial conception of health’ (2017) 389 Lancet 941, 941-943.
[3] Clare Bambra, Ryan Riordan, et al, ‘The COVID-19 pandemic and health inequalities’ (2020) 1 J Epidemiol Community Health 964, 965.
[4] Singer (n 23) 948.
[5] Harleen Kaur, ‘Indirect racial discrimination in COVID-19 ethical guidance’ (BMJ Blog, 27 August 2020) <https://blogs.bmj.com/covid-19/2020/08/27/indirect-racial-discrimination-in-covid-19-ethical-guidance/> accessed 8 January 2021.
[6] Bambra (n 24) 965-966.
[7] Melanie Moses, ‘A Model for a Just COVID-19 Vaccination Program’ (Nautilus, 25 November 2020) <http://nautil.us/issue/93/forerunners/a-model-for-a-just-covid_19-vaccination-program> accessed 8 January 2021.
[8] Tonia Poteat, ‘Understanding COVID-19 Risks and Vulnerabilities among Black Communities in America: Syndemics’ (2020) 47 Annals of Epidemiology 1, 3.
[9] Bambra (n 24) 966.
[10] National Academies (n 16) 30-31.
[11] ‘Beyond the data: Understanding the impact of COVID-19 on BAME groups’ (2020) Public Health England Report, 22-23 <https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/892376/COVID_stakeholder_engagement_synthesis_beyond_the_data.pdf> accessed 8 January 2021.
[12] Harald Schmidt, ‘Is It Lawful and Ethical to Prioritize Racial Minorities for COVID-19 Vaccines?’ (2020) 324 JAMA <https://jamanetwork.com/journals/jama/fullarticle/2771874> accessed 8 January 2021.
[13] Bambra (n 24) 967.
[14] Shruti Srivastava, ‘Millions Escaped Caste Discrimination. Covid-19 Brought It Back’ (Bloomberg Quint, 21 August 2020) <https://www.bloombergquint.com/politics/millions-escaped-caste-discrimination-covid-19-brought-it-back> accessed 8 January 2021.
[15] Ashwini Deshpande, ‘Differential impact of COVID-19 and the lockdown’ (The Hindu, 22 August 2020) <https://www.thehindu.com/opinion/lead/differential-impact-of-covid-19-and-the-lockdown/article32416854.ece> accessed 8 January 2021.
[16] Schmidt (n 33).
[17] Deshpande (n 36).
[18] Ibid.
[19] Olena Hankivsky, ‘An intersectionality-based policy analysis framework’ (2014) 13(119) Intl J Equity in Health 1, 2.
[20] Ibid.
[21] ‘Supporting older people during the COVID-19 pandemic’ (WHO, 3 April 2020) <https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/news/news/2020/4/supporting-older-people-during-the-covid-19-pandemic-is-everyones-business> accessed 8 January 2021.
[22] Awadhesh Kumar, ‘Impact of COVID-19 and comorbidities on health and economics’ (2020) 14(6) Diabetes Metab Syndr 1625, 1626-1627.
[23] Ibid.
[24] National Academies (n 16) 68-77.
Image Credit: One India
